Difference between revisions of "Well-Being Assessment"

Revision as of 11:14, 28 April 2015

The Patient Well-Being Assessment is a patient assessment designed to capture patient information with the goal of improving the patient's overall health and well-being. It captures the patient's determinants, barriers, symptoms and well-being status.

Physical Activity
1. In the past 7 days, how many days did you exercise? ___ days

2. On days when you exercised, for how long did you exercise (in minutes) ___ minutes per day   □ Does not apply

Tobacco Use
4. In the last 30 days, have you used tobacco? □ yes □ no

Alcohol Use
7. In the past 7 days, how many days did you drink alcohol? ____ days

8. On days when you drank alcohol, how often did you have ____ (5 or more for men, 4 or more for women and those men and women 65 years or over) alcohol drinks on one occasion?
□ Never
□ Once during the week
□ 2-3 times during the week
□ More than 3 times during the week

Nutrition
10. In the past 7 days, how many servings of fruit and vegetables do you eat per day?
(1 serving = 1 cup fresh vegetables, ½ cup cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball)
___ servings per day

11. In the past 7 days, how many servings of high fiber or whole grains food do you eat per day?
(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of brown rice or whole wheat pasta)
___ servings per day

12. In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day?
(Examples include fried chicken, fried fish, bacon, french fries, potato chips, corn chips, doughnuts, creamy salad dressing, and foods made with milk, cream, cheese, or mayonnaise.)
___ servings per day

13. In the past 7 days, how many sugar-sweetened (not diet) beverages did you consume each day?
___ sugar sweetened beverages consumed per day

Depression
15. In the past 2 weeks, how often have you felt down, depressed, or hopeless?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

16. In the past 2 weeks, how often have you felt little interest or pleasure in doing things?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

Anxiety
18. In the past 2 weeks, how often have you felt nervous, anxious, or on edge?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

19. In the past 2 weeks, how often were you not able to stop worrying or control your worrying? □ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

High Stress
20. How often is stress a problem for you in handling such things as:
- Your health?
- Your finances?
- Your family or social relationships?
- Your work?
□ Never or rarely
□ Sometimes
□ Often
□ Always

Social/Emotional Support
21. How often do you get the social and emotional support you need:
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Pain
22. In the past 7 days, how much pain have you felt?
□ None
□ Some
□ A lot

General Health
23. In general, would you say your health is
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor

24. How would you describe the condition of your mouth and teeth - including false teeth or dentures?
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor

Activities of Daily Living
25. In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking or using the toilet? □ yes □ no

Instrumental Activities of Daily Living
26. In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation or taking your medications? □ yes □ no

Sleep
27. Each night, how many hours of sleep do you usually get?
___ hours

29. In the past 7 days, how often have you felt sleepy during the daytime?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Blood Pressure - Self Reported
30. If your blood pressure was checked within the past year, what was it when it was last checked?
□ Low or normal (at or below 120/80)
□ Borderline high (120/80 to 139/89)
□ High (140/90 or higher)
□ Don't know/not sure

Cholesterol - Self Reported
31. If your cholesterol was checked within the past year, what was it when it was last checked?
□ Desirable (below 200)
□ Borderline high (200-239)
□ High (240 or higher)
□ Don't know/not sure

Blood Glucose - Self Reported
32. If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked?
□ Desirable (below 100)
□ Borderline high (100-125)
□ High (126 or higher)
□ Don't know/not sure

Fall Risk
40. How many time have you fallen in the past 12 months?
___ total number of times

Cognitive
41. In the past 7 days, I've had instances when I have forgotten things that recently happened
□ More than 10 times
□ 3 to 10 times
□ Once or twice
□ None

Patient Activation
42. In the past 7 days, I've had instances when I have forgotten things that recently happened
□ More than 10 times
□ 3 to 10 times
□ Once or twice
□ None